Artificial intelligence automated surgical phases recognition in intraoperative videos of laparoscopic pancreatoduodenectomy.

BACKGROUND: Laparoscopic pancreatoduodenectomy (LPD) is one of the most challenging operations and has a long learning curve. Artificial intelligence (AI) automated surgical phase recognition in intraoperative videos has many potential applications in surgical education, helping shorten the learning curve, but no study has made this breakthrough in LPD. Herein, we aimed to build AI models to recognize the surgical phase in LPD and explore the performance characteristics of AI models. METHODS: Among 69 LPD videos from a single surgical team, we used 42 in the building group to establish the models and used the remaining 27 videos in the analysis group to assess the models' performance characteristics. We annotated 13 surgical phases of LPD, including 4 key phases and 9 necessary phases. Two minimal invasive pancreatic surgeons annotated all the videos. We built two AI models for the key phase and necessary phase recognition, based on convolutional neural networks. The overall performance of the AI models was determined mainly by mean average precision (mAP). RESULTS: Overall mAPs of the AI models in the test set of the building group were 89.7% and 84.7% for key phases and necessary phases, respectively. In the 27-video analysis group, overall mAPs were 86.8% and 71.2%, with maximum mAPs of 98.1% and 93.9%. We found commonalities between the error of model recognition and the differences of surgeon annotation, and the AI model exhibited bad performance in cases with anatomic variation or lesion involvement with adjacent organs. CONCLUSIONS: AI automated surgical phase recognition can be achieved in LPD, with outstanding performance in selective cases. This breakthrough may be the first step toward AI- and video-based surgical education in more complex surgeries.

Textbook oncologic outcomes are associated with increased overall survival in patients with pancreatic head cancer after undergoing laparoscopic pancreaticoduodenectomy.

BACKGROUND: Textbook oncologic outcomes (TOO) have been used to evaluate long-term oncologic outcomes for patients after pancreaticoduodenectomy (PD) but not laparoscopic pancreaticoduodenectomy (LPD). The aim of the study was to assess the prognostic value of TOO for patients with pancreatic head cancer undergoing LPD and discuss the risk factors associated with achieving TOO. METHODS: Patients with pancreatic head cancer who underwent LPD in West China Hospital from January 2015 to May 2022 were consecutively enrolled. TOO was defined as achieving R0 resection, examination of ≥ 12 lymph nodes, no prolonged length of stay, no 30-day readmission/death, and receiving adjuvant chemotherapy. Survival analysis was used to determine the prognostic value of a TOO on overall survival (OS) and recurrence-free survival (RFS). Logistic regression was used to identify the risk factors of a TOO. The rates of a TOO and of each indicator were compared in patients who suffered or not from delayed gastric emptying (DGE). RESULTS: A total of 44 (25.73%) patients achieved TOO which was associated with improved median OS (TOO 32 months vs. non-TOO 20 months, P = 0.034) and a better RFS (TOO 19 months vs. non-TOO 13 months, P = 0.053). Patients suffering from DGE [odds ratio (OR) 4.045, 95% CI 1.151-14.214, P = 0.029] were independent risk factors for TOO. In addition, patients with DGE after surgery had a significantly lower rate of TOO (P = 0.015) than patients without DGE. CONCLUSIONS: As there were significant differences between patients who achieved TOO or not, TOO is a good indicator for long-term oncologic outcomes in patients with pancreatic head cancer after undergoing LPD. DGE is the risk factor for achieving TOO, so it is important to prevent the DGE after LPD to improve the rate of TOO.

Delayed gastric emptying after laparoscopic pancreaticoduodenectomy: a single-center experience of 827 cases.

BACKGROUND: Delayed gastric emptying (DGE) commonly occurs after pancreaticoduodenectomy (PD). Risk factors for DGE have been reported in open PD but are rarely reported in laparoscopic PD (LPD). This study was designed to evaluate the perioperative risk factors for DGE and secondary DGE after LPD in a single center. METHODS: This retrospective cohort study included patients who underwent LPD between October 2014 and April 2023. Demographic data, preoperative, intraoperative, and postoperative data were collected. The risk factors for DGE and secondary DGE were analyzed. RESULTS: A total of 827 consecutive patients underwent LPD. One hundred and forty-two patients (17.2%) developed DGE of any type. Sixty-five patients (7.9%) had type A, 62 (7.5%) had type B, and the remaining 15 (1.8%) had type C DGE. Preoperative biliary drainage (p = 0.032), blood loss (p = 0.014), and 90-day any major complication with Dindo-Clavien score ≥ III (p < 0.001) were independent significant risk factors for DGE. Seventy-six (53.5%) patients were diagnosed with primary DGE, whereas 66 (46.5%) patients had DGE secondary to concomitant complications. Higher body mass index, soft pancreatic texture, and perioperative transfusion were independent risk factors for secondary DGE. Hospital stay and drainage tube removal time were significantly longer in the DGE and secondary DGE groups. CONCLUSION: Identifying patients at an increased risk of DGE and secondary DGE can be used to intervene earlier, avoid potential risk factors, and make more informed clinical decisions to shorten the duration of perioperative management.

Laparoscopic Transduodenal Ampullectomy: How We Have Standardized the Technique (with Video).

BACKGROUND: The procedure of choice for the resection of ampullary tumors comprises transduodenal ampullectomy (TDA), endoscopic papillectomy (EP), and pancreaticoduodenectomy (PD).1 For neoplasms with low-grade dysplasia, TDA and EP have equivalent efficacies and lower morbidities than PD1. Compared with EP, also as an organ-preserving procedure, TDA could be applicable for tumors involving the pancreatic ducts or common bile ducts.2 Because TDA has a lower incidence of postoperative gastrointestinal bleeding and a higher R0 resection rate, its use could avoid the need to use multiple endoscopic procedures for larger lesions.3 Furthermore, during TDA, surgeons could convert to PD as necessary. However, TDA has rarely been performed using a minimally invasive approach that addresses the shortcomings of both the endoscopic and open surgical techniques without adding significant morbidity or compromising outcomes.2,4 Conventional laparoscopic TDA (LTDA) remains limited due to the complexity of the surgical anatomy of the ampulla and the reconstruction required compared with robot-assisted procedures.2-5 However, robot-assisted surgery is less popular and much more expensive than laparoscopic surgery. This report with a video describes the LTDA approach to standardize and simplify the surgical processes. METHODS: A 48-year-old man was admitted to the hospital with epigastric pain. He had a history of cholecystolithiasis with chronic cholecystitis. A tumor approximately 2.2 cm in diameter located in the duodenal papilla was diagnosed by an enhanced computed tomography (CT) scan. The endoscopic biopsy result indicated a villous adenoma with moderate dysplasia. Laparoscopic TDA and cholecystectomy were planned. However, if the frozen sample analysis showed adenocarcinoma, laparoscopic PD (LPD) would be applied. The patient was placed in the supine position with both legs apart. Trocars were distributed in the same manner as in the authors' previous study to facilitate conversion to LPD.6 The procedure began with kocherization and dissection of the gastrocolic ligament to explore the second and third portions of the duodenum. A figure-eight suture was made using 4-0 prolene in the seromuscular layer, and then the duodenum was retracted to the left side of the patient. A longitudinal duodenotomy was made, and the ampulla of Vater was identified. A transfixing suture was placed through the tumor. Submucosal injection of norepinephrine (1:500) was performed to divide the mucosa from the muscular planes. Ampullectomy was performed by first dissecting in the submucosal plane with a harmonic scalpel at the 6 o'clock position until the pancreatic duct was reached. A 6-Fr plastic catheter was inserted into the pancreatic duct for subsequent reconstruction. Continued dissection around the tumor identified the bile duct. Another 6-Fr plastic catheter was inserted into the bile duct. The dissection was completed in the submucosal plane, and the specimen was retrieved for frozen sectioning. After confirmation of villous adenoma with moderate dysplasia and the proximal margin without residual tumor on frozen biopsy, reconstruction was performed. The septum between the ducts was plastered, and the bile and pancreatic ducts were reconstructed on the duodenal wall with 5-0 PDS-II interrupted sutures to ensure that these ducts remained patent and connected. After reconstruction, the plastic catheter was kept in the pancreatic duct but removed from the bile duct. Then, cholecystectomy was applied. Finally, the duodenum was closed obliquely in two layers, and two drains were routinely placed. RESULTS: The operation time was 139 min, and the estimated blood loss was 50 ml. Final pathology confirmed villous adenoma with mild to moderate dysplasia. The postoperative course was uneventful, with a hospital stay of 9 days. There was no evidence of recurrence or patency of the reimplanted ducts 5 months after surgery. From February 2022 to May 2022, four cases of LTDA with the same surgical processes were managed by the authors, and all the patients recovered quickly without any postoperative complications. CONCLUSION: After standardization of the surgical processes, laparoscopic TDA was safe for highly selected patients. However, long-term follow-up is required to observe the quality of life and survival of patients.

Single-port laparoscopic pancreaticoduodenectomy.

BACKGROUND: Performing a single-port laparoscopic pancreatectomy is technically challenging. Single-port laparoscopic pancreaticoduodenectomy (SPLPD) is rarely reported in English literature. METHODS: Eighty-seven cases of laparoscopic pancreaticoduodenectomy (LPD) were performed by a single surgical team in the Department of Pancreatic Surgery, West China Hospital, Sichuan University between February 2020 and December 2020. Among these, 13 cases of LPD (group 1) were performed using a single-port device. Basing on the same inclusion and exclusion criteria, 68 cases of LPD performed using traditional 5-trocar were included as a control group (group 2). The patient's demographic characteristics, intraoperative, and postoperative variables were prospectively collected and retrospectively analyzed. RESULTS: Five men and eight women were included in the SPLPD group. The median age of these patients was 57 years. The patients who underwent SPLPD required a longer operative time (332.7 ± 38.1 min vs. 305.8 ± 64.7 min; p = 0.03) than those in the LPD group. The estimated blood loss, conversion rate, blood transfusion rate, time to oral intake, postoperative hospital stays, and perioperative complications were comparable between the two groups. The short-term oncological outcomes, such as R0 rate and lymph node harvested, were comparable between the two groups. The 90-day mortality of all patients was zero. CONCLUSIONS: SPLPD is a safe and feasible procedure for well-selected patients in an experienced minimally invasive pancreatic surgery team. SPLPD may provide several potential advantages, such as the requirement of fewer trocars, fewer abdominal complications, and reduced participation of assistants than conventional LPD.

The short- and long-term outcomes of laparoscopic pancreaticoduodenectomy combining with different type of mesentericoportal vein resection and reconstruction for pancreatic head adenocarcinoma: a Chinese multicenter retrospective cohort study.

BACKGROUND: The results of laparoscopic pancreaticoduodenectomy combining with mesentericoportal vein resection and reconstruction (LPD-MPVRs) for pancreatic head adenocarcinoma are rarely reported. The aim of present study was to explore the short- and long-term outcomes of different type of LPD-MPVRs. METHODS: Patients who underwent LPD-MPVRs in 14 Chinese high-volume pancreatic centers between June 2014 and December 2020 were selected and compared. RESULTS: In total, 142 patients were included and were divided into primary closure (n = 56), end-end anastomosis (n = 43), or interposition graft (n = 43). Median overall survival (OS) and median progress-free survival (PFS) between primary closure and end-end anastomosis had no difference (both P > 0.05). As compared to primary closure and end-end anastomosis, interposition graft had the worst median OS (12 months versus 19 months versus 17 months, P = 0.001) and the worst median PFS (6 months versus 15 months versus 12 months, P < 0.000). As compared to primary closure, interposition graft had almost double risk in major morbidity (16.3 percent versus 8.9 percent) and about triple risk (10 percent versus 3.6 percent) in 90-day mortality, while End-end anastomosis had only one fourth major morbidity (2.3 percent versus 8.9 percent). Multivariate analysis revealed postoperation hospital stay, American Society of Anesthesiologists (ASA) score, number of positive lymph nodes had negative impact on OS, while R0, R1 surgical margin had protective effect on OS. Postoperative hospital stay had negative impact on PFS, while primary closure, end-end anastomosis, short-term vascular patency, and short-term vascular stenosis positively related to PFS. CONCLUSIONS: In LPD-MPVRs, interposition graft had the worst OS, the worst PFS, the highest rate of major morbidity, and the highest rate of 90-day mortality. While there were no differences in OS and PFS between primary closure and end-end anastomosis.

Laparoscopic revision of duct-to-mucosa pancreaticojejunostomy anastomotic stricture after laparoscopic pancreaticoduodenectomy.

PURPOSE: Pancreaticojejunostomy stricture (PJS) is an uncommon late complication of laparoscopic pancreaticoduodenectomy (LPD). The incidence, clinical characteristics, and managements of PJS after LPD are still unreported. METHODS: All patients undergoing LPD between January 2015 and December 2019 were identified from an institutional database. All pancreaticojejunostomies were performed using Bing's duct-to-mucosa anastomosis. PJS was diagnosed by computed tomography or magnetic resonance cholangio-pancreatography with secretin administration. Re-operation was performed in those patients with persistent abdominal pain and/or recurrent pancreatitis. Patients' demographic characteristics, perioperative outcomes, and follow-up outcomes were retrospectively collected. RESULTS: During the 5-year study period, 506 cases of LPD were performed. Among these patients, 13 patients (2.6%) were diagnosed with PJS. Only seven patients presented with abdominal pain and/or recurrent pancreatitis and underwent re-operation. The interval between the diagnosis of PJS and the original operation was 23 months. The median operative time was 140 min (range 90 to 210 min). The estimated blood loss was 40 ml (range 10 to 100 ml). The post-operative outcomes were favorable. Only one patient suffered from biochemical fistula. Six of these 7 patients (85.7%) reported complete pain resolution after the re-operation. The other patient reported partial resolution after surgery. All patients did not need to take analgesic drugs after the operation. CONCLUSION: PJS following LPD is a late complication that was underestimated. It is technically safe and clinically effective to perform laparoscopic revision of the PJS after LPD.

Initial experience of single-incision plus one port total laparoscopic pancreaticoduodenectomy.

BACKGROUND: The use of single-incision plus one-port laparoscopic pancreaticoduodenectomy (SILPD + 1) has been never reported, and its safety and efficacy remain unknown. This study aimed to evaluate the short-term outcomes of SILPD + 1 compared with those of conventional laparoscopic pancreaticoduodenectomy (CLPD). METHOD: Fifty-seven cases of laparoscopic pancreaticoduodenectomy (LPD) were performed between November 2021, and March 2022. Among them, 10 cases of LPD were performed using a single-incision plus one-port device. Based on the same inclusion and exclusion criteria, 47 cases of LPD performed using traditional 5-trocar were included as a control group. The patient's demographic characteristics, intraoperative, and postoperative variables were prospectively collected and retrospectively analyzed. RESULTS: Three men and seven women were included in the SILPD + 1 group. All baseline parameters of both groups were comparable, except for age. Patients were younger in the SILPD + 1 group (47.2 ± 18.3 years vs. 60.6 ± 11.7 years, P = 0.05) than that in the CLPD group. Compared with the CLPD group, median operation time (222.5 (208.8-245.0) vs. 305.0 (256.0-37.0) min, P < 0.001) was shorter, median postoperative VAS scores on days 1-3 were lower, and median cosmetic score (21.0 (19.0-23.5) vs. 17.0 (16.0-20.0), P = 0.026) was higher one month after the surgery in the SILPD + 1 group. The estimated blood loss, conversion rate, blood-transfusion rate, exhaust time, time of drainage tube removal, postoperative hospital stays, and perioperative complications were comparable between the two groups. CONCLUSION: In a high-volume LPD center, SILPD + 1 is safe and feasible for well-selected patients without increasing the operation time and complications. It even has the advantages of reduced postoperative pain and improved cosmetic results.

Laparoscopic parenchyma-sparing resections for solid pseudopapillary tumors located in the head of pancreas.

BACKGROUND: Solid pseudopapillary tumor (SPT) of the pancreas is a rare low-grade malignant tumor. Here, we aimed to determine the safety and feasibility of laparoscopic parenchyma-sparing pancreatectomy for SPT located in the pancreatic head. METHODS: From July 2014 to February 2022, 62 patients with SPT located in the pancreatic head were operated laparoscopically in two institutions. These patients were divided into two groups according to the operative strategy: laparoscopic parenchyma-sparing pancreatectomy (27 patients, group 1) and laparoscopic pancreaticoduodenectomy (35 patients, group 2). The clinical data were retrospectively collected and analyzed in terms of demographic characteristics, perioperative variables, and long-term follow-up outcomes. RESULTS: The demographic characteristics of the patients in the two groups were comparable. Compared to the patients in group 2, those in group 1 required less operative time (263.4 ± 37.2 min vs. 332.7 ± 55.6 min, p < 0.001) and experienced less blood loss (105.1 ± 36.5mL vs. 188.3 ± 150.7 mL, p < 0.001). None of the patients in group 1 had tumor recurrence or metastasis. However, 1 (2.5%) patient in group 2 showed liver metastasis. CONCLUSION: Laparoscopic parenchyma-sparing pancreatectomy is a safe and feasible approach for SPT located in the pancreatic head, with favorable long-term functional and oncological results.

"Plane first" approach for laparoscopic radical antegrade modular pancreatosplenectomy.

BACKGROUND: Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has not been widely performed due to its technical challenging. We introduce a novel approach, named "Plane first" approach, for L-RAMPS in this study. METHODS: From January 2015 to August 2021, we performed 51 cases of L-RAMPS. Patients were divided into two groups basing on the surgical approach: conventional approach (group 1) and "Plane first" approach (group 2). Data were retrospectively collected in terms of demographic characteristics, intra-operative variables, post-operative variables, and follow-up outcomes. RESULTS: The age, sex, BMI, and tumor size were comparable between two groups. Two patients in the group 1 required converting to open surgery. The patients in the group 2 required fewer operative time (210.5 ± 65.5 min vs. 252.4 ± 24.7 min, p < 0.01). They also suffered from less blood loss (136.0 ± 100.0 ml vs. 158.8 ± 137.0 ml, p = 0.15). The overall complications for patients in two groups were comparable. In terms of oncological outcomes, posterior margin was positive in two patients (10.5%) in the group 1. One patient (3.1%) in the group 2 had positive pancreatic neck margin. The number of lymph nodes harvested and overall survival between the two groups were comparable. CONCLUSION: "Plane first" approach RAMPS for patients with pancreatic adenocarcinoma in the left pancreas is safe and feasible, even in patients with PV/SMV involvement.

Pancreaticojejunostomy without pancreatic duct stent after laparoscopic pancreatoduodenectomy: preliminary outcomes from a prospective randomized controlled trial.

BACKGROUND: Outcomes of pancreaticojejunostomy without pancreatic duct during open pancreaticoduodenectomy (OPD) are unknown and controversial, and corresponding reports in laparoscopic surgery are lacking. METHODS: Patients were evaluated at West China Hospital, and standard laparoscopic pancreaticoduodenectomy (LPD) was planned. A prospective randomized trial was conducted, in which the patients were randomly assigned to the no-stent and internal-stent groups in a single-center trial. The primary outcomes were the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) and 90-day mortality. Preliminary results were reported. RESULTS: From November 2019 to March 2021, we enrolled 90 patients (41 in the no-stent group and 49 in the internal-stent group) in the study. All baseline parameters of both groups, including age, sex ratio, pancreatic duct diameter, and intraoperative blood loss, were comparable between the two groups except for pathological diagnosis and the texture of remnants. Twenty-seven (65.9%) and 19 (38.8%) patients in the no-stent and internal-stent groups, respectively, had soft pancreatic remnants (P = 0.010). The total incidence of CR-POPF was 5.6% and included two patients (4.9%) in the no-stent group and three patients (6.1%) in the internal-stent group (P = 1.000). Only one patient in the internal-stent group died of heart failure within 90 days after the operation. No significant difference in other postoperative complications was observed between the groups except for biochemical fistula [no-stent group vs. internal-stent group = 31.7% vs. 12.2%, (P = 0.024)]. CONCLUSIONS: In a high-volume LPD center, duct-to-mucosa pancreaticojejunostomy without pancreatic duct stent is safe and reliable. In addition, duct-to-mucosa pancreaticojejunostomy without pancreatic duct stent was more challenge. We recommend using the stent during anastomosis and pulling it out after the procedure.

Practice Patterns and Perioperative Outcomes of Laparoscopic Pancreaticoduodenectomy in China: A Retrospective Multicenter Analysis of 1029 Patients.

OBJECTIVE: The aim of the study was to analyze the outcomes of patients who have undergone laparoscopic pancreaticoduodenectomy (LPD) in China. SUMMARY BACKGROUND DATA: LPD is being increasingly used worldwide, but an extensive, detailed, systematic, multicenter analysis of the procedure has not been performed. METHODS: We retrospectively reviewed 1029 consecutive patients who had undergone LPD between January 2010 and August 2016 in China. Univariate and multivariate analyses of patient demographics, changes in outcome over time, technical learning curves, and the relationship between hospital or surgeon volume and patient outcomes were performed. RESULTS: Among the 1029 patients, 61 (5.93%) required conversion to laparotomy. The median operation time (OT) was 441.34 minutes, and the major complications occurred in 511 patients (49.66%). There were 21 deaths (2.43%) within 30 days, and a total of 61 (5.93%) within 90 days. Discounting the effects of the early learning phase, critical parameters improved significantly with surgeons' experience with the procedure. Univariate and multivariate analyses revealed that the pancreatic anastomosis technique, preoperative biliary drainage method, and total bilirubin were linked to several outcome measures, including OT, estimated intraoperative blood loss, and mortality. Multicenter analyses of the learning curve revealed 3 phases, with proficiency thresholds at 40 and 104 cases. Higher hospital, department, and surgeon volume, as well as surgeon experience with minimally invasive surgery, were associated with a lower risk of surgical failure. CONCLUSIONS: LPD is technically safe and feasible, with acceptable rates of morbidity and mortality. Nonetheless, long learning curves, low-volume hospitals, and surgical inexperience are associated with higher rates of complications and mortality.

Laparoscopic duodenum-preserving total pancreatic head resection using real-time indocyanine green fluorescence imaging.

BACKGROUND: It is technical challenging to perform laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). Only a few case reports and case series of LDPPHR are available in the literature. MATERIALS AND METHODS: From February 2019 to November 2019, 24 cases of LDPPHR were carried out in the Department of Pancreas Surgery, West China Hospital, Sichuan University. Data were prospectively collected in terms of demographic characteristics (age, gender, BMI, and pathological diagnosis), intraoperative variables (operative time, estimated blood loss, transfusion, pancreatic texture, and diameter of main pancreatic duct), and post-operative variables (time for oral intake, post-operative hospital stay, and complications). RESULTS: Nine male patients and fifteen female patients were included in this study. The median age of these patients was 43 years. All patients underwent duodenum-preserving total pancreatic head resection laparoscopically. The median operative time was 255 min. The median estimated blood loss was 200 ml. One patient required blood transfusion. The median post-operative hospital stay was 10 days. Three patients suffered from biliary fistula. Eleven patients (45.8%) suffered from pancreatic fistula; however, only one patient (4.2%) suffered from grade B pancreatic fistula. No patient suffered from grade C pancreatic fistula. One patient with chronic pancreatitis required re-operation for jejunal anastomotic bleeding on the first post-operative day. No patient suffered from gastroparesis, duodenal necrosis, or abdominal bleeding. The 30-day mortality was 0. CONCLUSION: LDPPHR is safe and feasible. Real-time indocyanine green fluorescence imaging may help prevent bile duct injury and bile leakage.

Laparoscopic partial splenectomy with temporary occlusion of the trunk of the splenic artery in fifty-one cases: experience at a single center.

BACKGROUND: Laparoscopic partial splenectomy (LPS) for splenic benign space-occupying lesions has been reported by many researchers; however, few studies have described methods to control intraoperative bleeding. Trustworthy experience in LPS with a satisfactory intraoperative hemorrhage control technique is therefore necessary. The current study aims to present our experience in LPS with temporary occlusion of the trunk of the splenic artery for controlling intraoperative bleeding with a large sample of 51 cases and to evaluate the safety, feasibility, and reproducibility of this technique. METHODS: Fifty-one patients from August 2014 to April 2019 who underwent LPS in our institution were retrospectively analyzed. Surgical techniques were described in detail. RESULTS: All patients had successfully undergone LPS with temporary occlusion of the trunk of the splenic artery. Conversions to open surgery, hand-assisted laparoscopic splenectomies, or blood transfusions were not needed. The operative time was 94.75 ± 18.91 min, the estimated blood loss was 71.13 ± 53.87 ml, and the volume of resected spleen was 34.75 ± 12.19%. The range of postoperative stays was 4-14 days. One female patient (2%, 1/51) suffered from postoperative complications. No perioperative mortality, incision infections, postoperative pancreatic fistulas (POPFs), splenic infarctions, or portal/splenic vein thromboembolic events occurred. CONCLUSION: LPS is an effective spleen-preserving surgery. Although there are many other bleeding control methods, temporarily occluding the trunk of the splenic artery was found to be a safe, feasible, and reproducible technique in LPS. The outcomes of this technique and the efficacy of splenic parenchyma preservation are acceptable.

Anterior approach in situ resection for total laparoscopic pancreaticoduodenectomy.

BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD) is gaining popularity in last decade. However, it is still technical challenging to perform LPD for patients with large periampullary tumors. METHODS: From January 2019 to January 2020, 13 cases of LPD were performed via anterior approach. Data were collected prospectively in terms of demographic characteristics (age, gender, body mass index, pathological diagnosis and tumor size), intra-operative variables (operative time, estimated blood loss, transfusion), and post-operative variables (time for oral intake, post-operative hospital stay, and complications). RESULTS: There were five male patients and eight female patients included in this study. The median age of these patients was 52.7 ± 14.5 years. The median size of tumors was 7.2 ± 2.9 cm. One patient converted to open surgery because of uncontrollable hemorrhage. The median operative time was 356 ± 47 min. The median estimated blood loss was 325 ± 216 ml. The mean post-operative hospital stay was 12.4 ± 1.9 days. One patient suffered from grade B pancreatic fistula. One patient suffered from delayed gastric emptying which was cured by conservative therapy. 90-day mortality was zero. CONCLUSIONS: Laparoscopic pancreaticoduodenectomy via anterior approach is safe and feasible for patients with large periampullary tumors. Its oncological benefit requires further investigation.

Wrapping the stump of the gastroduodenal artery using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a center's preliminary experience.

BACKGROUND: The present study aims to assess the preliminary outcomes of the effectiveness of wrapping the ligamentum teres hepatis (LTH) around the gastroduodenal artery stump for the prevention of erosion hemorrhage after laparoscopic pancreaticoduodenectomy (LPD). METHODS: We reviewed 247 patients who had undergone LPD between January 2016 and April 2019. The patients were divided into two groups according to whether LTH wrapped the stump of the gastroduodenal artery: group A (119 patients) who underwent the LTH wrapping procedure, and group B (128 patients) who did not undergo the procedure. The perioperative data from the two groups were reviewed to assess the effectiveness of the LTH procedure for the prevention of postpancreatectomy hemorrhage (PPH) and other complications. RESULTS: No differences were observed in the clinical characteristics between the two groups. The data from 247 patients were acceptable for analysis: 119 patients underwent wrapping, and 128 patients did not. The incidence of clinically relevant pancreatic fistula (8.4% vs 3.9%), biliary fistula (2.5% vs 1.6%), intra-abdominal infection (10.1% vs 3.9%) and delayed gastric emptying (13.4% vs 16.4%) showed no significant difference between group A and group B. The 90-day mortality and 90-day reoperation rates (0.8% vs 0.8% and 5.0% vs 3.1%) were also similar between group A and group B. Furthermore, postpancreatectomy hemorrhage of Grade B and C occurred in 0 patients (0.0%) in the wrapping group, which was significantly less frequent than the occurrence in the nonwrapping group (7 patients; 5.5%, P = 0.02). CONCLUSIONS: Wrapping the LTH around the gastroduodenal artery stump after LPD does not reduce the incidence of clinically relevant pancreatic fistula, biliary fistula or delayed gastric emptying. However, this procedure has a trend of reducing the rate of PPH of Grade B and C after LPD and is simple to perform.

Dynamic prediction for clinically relevant pancreatic fistula: a novel prediction model for laparoscopic pancreaticoduodenectomy.

BACKGROUND: With the recent emerge of dynamic prediction model on the use of diabetes, cardiovascular diseases and renal failure, and its advantage of providing timely predicted results according to the fluctuation of the condition of the patients, we aim to develop a dynamic prediction model with its corresponding risk assessment chart for clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy by combining baseline factors and postoperative time-relevant drainage fluid amylase level and C-reactive protein-to-albumin ratio. METHODS: We collected data of 251 patients undergoing LPD at West China Hospital of Sichuan University from January 2016 to April 2019. We extracted preoperative and intraoperative baseline factors and time-window of postoperative drainage fluid amylase and C-reactive protein-to-albumin ratio relevant to clinically relevant pancreatic fistula by performing univariate and multivariate analyses, developing a time-relevant logistic model with the evaluation of its discrimination ability. We also established a risk assessment chart in each time-point. RESULTS: The proportion of the patients who developed clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy was 7.6% (19/251); preoperative albumin and creatine levels, as well as drainage fluid amylase and C-reactive protein-to-albumin ratio on postoperative days 2, 3, and 5, were the independent risk factors for clinically relevant postoperative pancreatic fistula. The cut-off points of the prediction value of each time-relevant logistic model were 14.0% (sensitivity: 81.9%, specificity: 86.5%), 8.3% (sensitivity: 85.7%, specificity: 79.1%), and 7.4% (sensitivity: 76.9%, specificity: 85.9%) on postoperative days 2, 3, and 5, respectively, the area under the receiver operating characteristic curve was 0.866 (95% CI 0.737-0.996), 0.896 (95% CI 0.814-0.978), and 0.888 (95% CI 0.806-0.971), respectively. CONCLUSIONS: The dynamic prediction model for clinically relevant postoperative pancreatic fistula has a good to very good discriminative ability and predictive accuracy. Patients whose predictive values were above 14.0%, 8.3%, and 7.5% on postoperative days 2, 3, and 5 would be very likely to develop clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy.

Laparoscopic Pancreaticoduodenectomy: Outcomes and Experience of 550 Patients in a Single Institution.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy (LPD) is one of the most technically challenging surgical procedures, involving complicated dissection and reconstruction. Recently, enthusiasm for performing this procedure has increased; however, concerns have been raised regarding its perioperative and oncologic outcomes. METHODS: We retrospectively reviewed patients who underwent LPD between 2010 and 2019 at our institution. We analyzed perioperative and oncologic outcomes of LPD, risk factors associated with complications, and the learning curve. RESULTS: 550 patients underwent LPD, including 473 standard LPD and 77 LPD with vascular resection. Of these, 38.5% experienced complications. Pancreatic fistula occurred in 24% of patients. Five patients died within 90 days. No significant differences were observed in terms of complications or 90-day mortality between patients who underwent LPD with vascular resection versus standard LPD. Patients with pancreatic cancer had the shortest median survival time (20 months); patients with duodenal or papillary cancer had the longest median survival time (50 months). Pancreatic cancer, American Society of Anesthesiologists (ASA) score, and operative time were risk factors associated with complications, and previous abdominal surgery, ASA score, and body mass index were risk factors associated with severe complications. Finally, surgeons who performed standard LPD had a learning period of 47 procedures, whereas surgeons who performed LPD with vascular resection were proficient after having performed 200 standard LPD procedures. CONCLUSIONS: LPD is a safe, feasible, and oncologically acceptable procedure when performed in a high-volume center. Performance of LPD should follow a step-by-step principle because of the long and steep learning curve.

Indocyanine Green-Enhanced Fluorescence in Laparoscopic Duodenum-Preserving Pancreatic Head Resection: Technique with Video.

BACKGROUND: In 1972, Beger et al.1 first described duodenum-preserving pancreatic head resection (DPPHR) for patients with severe chronic pancreatitis. Then DPPHR also was proved capable of providing comparable long-term oncologic outcomes in the setting of benign or low-grade malignant tumors.2 As an organ-preserving procedure, DPPHR preserves the integrity of the digestive tract and improves the patient's quality of life compared with pancreaticoduodenectomy (PD),3 although DPPHR is more technically challenging, especially in protecting the bile duct and the pancreaticoduodenal vascular arch.4,5 The indocyanine green (ICG)-enhanced fluorescence imaging system in laparoscopic surgery can identify the biliary and vascular anatomy clearly to ensure a safe cholecystectomy and an adequate vascular supply for colectomy or nephrectomy.6 Nevertheless, to date, no report has described ICG-enhanced fluorescence in laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). This article describes the technique of LDPPHR using a video of a real-time ICG fluorescence imaging system. METHODS: A 29-year-old woman received a diagnosis of chronic pancreatitis and an inflammatory mass in the head of the pancreas. A computed tomography (CT) scan showed atrophy of the pancreas, dilation of the main pancreatic duct, and heterogeneous enhancement of the pancreatic head parenchyma (Fig. 1). Her other preoperative examination results were normal except for high blood sugar. To avoid an extended PD for this young patient, LDPPHR was performed. The patient was placed in supine position with her two legs apart. The observing trocar (10 mm) was located at the inferior umbilicus. Four trocars (two 5-mm trocars and two 12-mm trocars) were distributed symmetrically at the midclavicular line and anterior axillary line. Another 5-mm trocar located at the subxiphoid was used for traction of the stomach with a rubber band. Before the operation, ICG (5 mg) was injected intravenously from the elbow vein. The gastrocolic ligament was opened, and the hepatic flexure of the colon was taken down to explore the head of the pancreas without making a Kocher's maneuver. After hanging of the distal stomach with a rubber band, both the right gastroepiploic vein and Henle's trunk were dissected. The number 8a lymph node was dissected for intraoperative rapid frozen pathology. A post-pancreatic neck tunnel was built, and the pancreatic neck was transected with an ultrasonic scalpel. The main pancreatic duct was identified and transected with cold scissors. The superior mesenteric vein (SMV) was hung with another rubber band and retracted to the left. The uncinate process of the pancreas was retracted to the right, and subcapsular dissection was performed, with particular attention paid to protection of the anterior inferior pancreaticoduodenal artery (AIPDA), the posterior inferior pancreaticoduodenal artery (PIPDA), and their branches that go into the duodenum. Then the gastroduodenal artery (GDA) was identified, and the anterosuperior pancreatic duodenal artery (ASPDA) was dissected. The upper part of the pancreatic head was separated to expose the common bile duct (CBD) with the help of real-time ICG fluorescence imaging (Fig. 2). The pancreas was dissected from the left edge of the duodenum and the right and ventral edges of the CBD. The posterosuperior pancreatic duodenal artery (PSPDA) was identified at the dorsal edge of the CBD. The PSPDA and its branches going into the distal CBD as well as the ampulla of Vater were carefully preserved. The proximal side of the main and accessory pancreatic duct was identified and sutured. Pancreatic anastomosis was performed using the technique of Bing's anastomosis.7 Fig. 1 Enhanced computed tomography (CT) scan showing atrophy of the pancreas, dilatation of the main pancreatic duct, and heterogeneous enhancement of the pancreatic head parenchyma Fig. 2 The common bile duct was separated and exposed from the head to the tail by the assistance of the real-time indocyanine green (ICG)-enhanced fluorescence imaging system RESULTS: The operation time was 251 min, and the estimated blood loss was 150 ml. The postoperative course was uneventful, with a hospital stay of 13 days. From February 2019 to November 2019, LDPPHR was used by the authors to manage 24 cases, including chronic pancreatitis (6 cases), pancreatic intraductal papillary mucinous tumors (6 cases), pancreatic neuroendocrine tumors (4 cases), pancreatic solid pseudopapillary tumors (4 cases), serous cystadenoma (3 cases), and mucinous cystadenoma (1 case). CONCLUSIONS: Indocyanine green-enhanced fluorescence in laparoscopic duodenum-preserving pancreatic head resection was safe and may offer a benefit for maintaining the integrity of the biliary system.

Laparoscopic Beger procedure for the treatment of chronic pancreatitis: a single-centre first experience.

BACKGROUND: The Beger procedure is a common surgical option in the management of the unremitting abdominal pain of chronic pancreatitis (CP). As an organ-sparing surgery, it might be a better choice than pancreatoduodenectomy (PD). However, it is rather challenging for surgeons to perform the Beger procedure laparoscopically, especially for patients with CP; indeed, it has rarely reported. Here, we describe the technique and results of our early experience in laparoscopic Beger procedure for the treatment of CP. CASE PRESENTATION: Five patients (1 male) with CP (alcohol induced, n = 3; idiopathic, n = 2) who underwent laparoscopic Beger procedure from May to October 2019 in West China Hospital were included in this study. The median pancreatic duct diameter was 6.8 (4 to 12) mm. The median operating time was 275 (150 to 305) minutes without conversion. Only one patient (20%) developed a grade B pancreatic fistula. One patient required re-operation for jejunal anastomotic bleeding on the first post-operative day. The median hospital stay was 11 (9 to 34) days. No patient experienced biliary fistula, gastroparesis, duodenal necrosis, or abdominal bleeding. The 90-day mortality rate was 0%. All the patients were pain free in the two months after the operation. CONCLUSION: The laparoscopic Beger procedure is feasible and safe with good short-term results and some potential benefits in selected patients with chronic pancreatitis. Further study and longer follow-up are required.